Plastic Kabul

23 February 2015

What the recent boom in the cosmetic industry means for the Afghan middle class.

Hamkar Plastic Surgery Hospital, Kabul.Photo: Ali Latifi

Situated just next to a large roundabout, the Hamkar Plastic Surgery Hospital should be easy to find.

But this is Kabul, not an episode of Nip/Tuck.

In place of a sleek building that reflects the clean, simple standards of contemporary design is a metallic edifice still under construction where workers in hospital scrubs and surgical masks paint the walls and install light fixtures. Instead of electronic and new-age music, the sounds of saws and hammers are heard, as patients enter a bare lobby leading to a flight of stairs being mopped by nurses. The surrounding, evoking a sense of incompletion, may not be what one usually associates with an industry often seen to be indulging in a profligate exercise of turning out new tropes of ‘perfection’. But it is very much in line with life in the new Kabul.

Nestled along the dirt road of the Char Rahi Sar Sabzi, Dr Aminullah Mohammad Ehsan Hamkar’s eponymous private clinic is upstaged by the relative opulence of another of the Afghan capital’s nouveau riche icons – wedding halls. With their multicoloured flashing lights and replicas of the Eiffel Tower, the wedding halls easily draw attention away from a clinic, which according to Hamkar, performs procedures that rival Western practices in their quality and precision.

My father doesn’t know I’m here. He is against altering god’s work.

What kind of plastic?Hamkar, who began his PhD in Moscow just after the communist putsch and completed it before the end of the civil war in Afghanistan, hopes his practice will stand out not only from the garish saloon-e-aroosi, but also the many other cosmetic surgery practices that have sprung up around Kabul.

After completing his studies in Dushanbe and Moscow, Hamkar was startled to find people ‘passing themselves off’ as plastic surgeons in Kabul after having worked a month or two with foreign surgeons. At best, those who had earned certificates in neighbouring Pakistan would perform cosmetic procedures. Before Hamkar started his private reconstructive and plastic surgery practice more than ten years ago, doctors would ask him, “what kind of plastic do we use?” Questions like this alerted him to the dangers presented by the lack of proper regulations and oversight at multi-level surgical centres operating in broad daylight in the capital.

Hamkar hopes to change that and bring a renewed sense of professional competency to cosmetic and reconstructive surgery in Kabul. The fledgling cosmetic surgery industry he helped found has its share of critics. However, as he sees it, the economic realities of the nation are changing: “Afghanistan has a middle class now.”

Despite the perceived economic advancements, the more conservative mores that have seeped into Kabul since the civil war of the 1990s remain largely unchanged.

Still recuperating from an eyelid tuck, 28-year-old Tahmena said it was frustration at people staring at her eyes that led her to seek the services of Hamkar and his associates. “I wanted to be beautiful,” she tells me less than 24 hours after her surgery. Tahmena seems very pleased with the initial results. However, as she carefully holds her brightly-coloured floral print scarf to shield her face in an otherwise empty hospital room, Tahmena hopes the results are not too dramatic.

“My father doesn’t know I’m here. He is against altering god’s work,” she said in a hushed tone. Without her father’s support, Tahmena had to work to assuage the concerns of her mother. Aside from the objection that man should not alter what god created, Tahmena’s mother was worried for her daughter’s health. However her mother slowly came around to a hesitant acceptance. “She finally said ‘If it makes you happy…’”

Religious objections to cosmetic procedures are nothing new. When confronted with statements about man’s hands interfering with what god created, Hamkar, who also does plastic and reconstructive surgery at the Maiwand Teaching Hospital, says, “God also makes cleft palettes. If you touch one thing, why not another?” If the practical example of children unable to properly eat or drink due to a malformation does not suffice, Hamkar turns to a source few religious persons in Afghanistan are likely to dispute, Prophet Muhammad himself: “Allah is beautiful and He loves beauty.”

Permission was only one of the obstacles Tahmena had to surmount before having her procedure. There was still the matter of payment. Though he too initially objected to an ‘overpriced vanity’, Tahmena’s older brother fronted her the money for the procedure. Unwilling to provide an exact figure, Tahmena only told me the procedure cost “several hundred dollars”.

Hamkar maintains that what his clinic charges for popular procedures – between USD 350 and USD 450 for rhinoplasty – is what “clinics [in other countries] charge for lab results”. But even with a rising ‘middle class’, 20,000 Afghanis is no small sum for many people.

Reconstructive surgeryOnly a day prior, while Tahmena was undergoing her procedure, the still empty halls of the lobby echoed with the sounds of an argument between an elderly man and hospital staff. “How long will the procedure take? How long is the post-op stay? The price will be very different if it’s two days or five, I need to know in writing what it costs,” the man who traveled to Kabul specifically for an unnamed procedure could be heard asking.

But it was a different question he asked that highlighted the contrast between cosmetic and reconstructive surgery in Afghanistan: “Do I need to pay for my own medicine and supplies?”

Though the hospital staff assured the man that any supplies or medication needed during the surgery would be provided by the hospital, his question was indicative of just how much access to medical care can be affected by finance in Afghanistan. Legally, public healthcare has always been free in Afghanistan. But with a GDP of around USD 20 billion and rampant corruption, Hamkar says, “all that is ‘free’ are these four walls.”

Patients often have to supply everything from medicine to gauze before a procedure can be performed. Despite a lot of international aid spent on developing healthcare systems in Afghanistan, the Afghan health system lags behind even where it was 30 years ago. Prior to the wars and only a few months before Hamkar left for the Tajik capital to study, Afghan hospitals were fully capable of radiotherapy treatments. Today, the nation lacks the equipment for both radiotherapy and chemotherapy, and has to send a large number of patients suffering from all kinds of cancer to Pakistan for treatment.

Maiwand Teaching Hospital, Kabul.Photo: Ali Latifi

For Hamkar, the economics of skin-cancer treatment, in particular, is significant: “it is the poorest people who work out in the sun all day that suffer from skin cancer.”

“We have democracy and a free market now, but we still have to beg other countries for aid. How can we call this national healthcare?” Hamkar asks. But Mustafa Sahibzada, who works in the dermatology wing of Maiwand Teaching Hospital, fears for his patients who come from some of the country’s poorest provinces such as Bamiyan, Daikundi and Baghlan. If the government stops even their most basic subsidies for healthcare services, and public institutions like Maiwand begin charging, “who will put a cap on prices,” he asks. Several patients wait for days, even weeks, at Maiwand Hospital until they themselves can procure the necessary equipment for their surgery. Most of these patients come from neighbouring provinces by selling what few valuable possessions they have to pay for the trip to the capital.

What is most evident about foreign coverage of these surgical centres is that they once again show the oversimplification and glorification of a new phenomenon in Afghanistan.

Only a flight of stairs above Hamkar’s office sit patients from Maidan Wardak and Baghlan provinces, anxiously awaiting treatment. Mariam, a 25-year-old woman from Baghlan province has waited more than two months in two hospitals for treatment for the burns she received after a gas explosion in the provincial capital of Pol-e Khomri. The burns across her face have left her unable to close her eyes and dried out her tear ducts. She has already spent six days in the Maiwand hospital but must spend another ten days there before she can be operated on.

Looking at two-and-a-half-year-old Alem from Maidan Wardak province, Hamkar says journalists often want to write about his cosmetic surgery practice, but few pay attention to cases like the little boy who will have to spend ten more days waiting for surgery after already having waited six months.

Though the staff at Maiwand hospital say they are technically capable of treating cleft palette and cleft lip, I am told finances will impact Alem’s proper recovery. “The surgery is easy, but cleft palette treatment is of little use without speech therapy.” In 2009, a French NGO promised to provide speech therapy facilities to Maiwand Hospital, but Hamkar says, “I haven’t seen them since. Everyone makes promises here.”

Beauty standardsSeveral foreign media outlets have written about the cosmetic surgery ‘boom’ in Kabul. Fashion magazine Marie Claire cited clinics like Hamkar’s as “a huge change in Afghan society”. But for many Afghans, the Western media stories of the “surprise” that “looks count” in Afghanistan, leave out one important factor – race.

Having read several stories with headlines such as “New noses mean new lives in Afghanistan”, Noorjahan Akbar, a women’s rights activist in Kabul, could not shake the sense of ethnocentrism that permeated the stories about ‘cosmetics replacing prosthetics’ in Kabul. In an interview with me, Akbar said on reading the glut of stories about cosmetic surgery in Afghanistan, it became clear to her that many of the people cited as wanting “bigger noses and wider eyes” in the articles were of the Hazara minority, a people historically oppressed in Afghanistan.

“It is a fascist beauty standard that make many Hazaras, especially women, feel that they are not beautiful, because of a literature that promotes Aryan beauty, large eyes, and the like,” Akbar said.

Jawad Zawullistani, an ethnic Hazara from southeastern Afghanistan, agrees: “Look how many poems refer to a ‘sword-like’ nose. This is what people grow up reading.”

Though Western stories about cosmetic surgery in Afghanistan tend to highlight the sense of agency many women of the country gain from these procedures, Akbar, herself of mixed ethnicity, sees something equally disturbing from a different vantage point. In a November 2012 blog post, Akbar criticised Nip, Tuck Kabul, a British documentary about the apparent ‘personal freedom’ two Hazara women exercised by getting plastic surgery. In place of the ‘promise of emancipation’ which the filmmakers Leslie Knott and Clementine Malpas saw, Akbar was struck by two women who were “at the cosmetic surgery clinic to erase from their face, literally, their ethnic identity.”

The pressures of Aryan beauty standards do not begin in Afghanistan, according to Zawullistani: “The majority of Hazaras who fled in the last 30 years went to Iran, where cosmetic surgery and a focus on physical beauty is so prevalent. Of course, that mindset will stay with them when they return to Afghanistan.” The pressure to fit in physically is just as prevalent in the Islamic Republic, where Afghan migrants are often referred to with the pejorative ‘Afghani’. He told me, “When they say ‘Afghani’, Iranis often mean Hazara. Again, the same social pressures to fit in rather than stand out follow Hazara migrants when they leave the country.”

Sradda Thapa, a Kabul-based development specialist, says it is not just Afghanistan that must deal with racially or ethnically motivated plastic surgeries. Thapa points to the booming skin-bleaching industry in the Subcontinent and the prevalence of eyelid surgery in South Korea as examples of what standardised notions of beauty can do.

In the end, what is most evident about foreign coverage of these surgical centres is that they once again show the oversimplification and glorification of a new phenomenon in Afghanistan. Whereas Western journalists who may have once written about the ‘oppressive’ chadari – what in the West has come to be known as the burqa – now write glowingly about a pursuit of an ideal of beauty, some Afghans see this merely as a new solution to a series of long-standing issues that afflict all nations subjected in one form or another to colonial standards of beauty. As Thapa argues, “It’s much more worth our time – both as an intellectual exercise and in practice – to consider how rational beings decide on such an act: what are the circumstances and forces at play? Can we just discourage a 26-year-old girl from getting that surgery or do we address larger problems in our society where women in advertisement are primarily blonde or big-eyed or white? Perhaps pursuing such questions would reveal the reasons, and it’s the reasons not the acts that need our attention.”

~ Ali Latifi is a Kabul-born, California-raised journalist who has covered Afghanistan for the Los Angeles Times, the New York Times, Al Jazeera English and VICE News. Latifi currently resides in Kabul.